Introduction
During armed conflict and terrorist events, explosive devices can cause colorectal wounds secondary to blast effects.Reference Paran, Neufeld and Shwartz 1 Particularly important in this respect are blasts from improvised explosive devices (IEDs), bombs, and mines.Reference Webster, Mercer, Schrager, Carrell and Bowley 2 The colorectal lesions caused by explosive blast are produced by the energy transfer of expansive shock waves. It is important to recognize these types of internal injuries which are often not apparent clinically on admission to an emergency department; particularly when these injuries are overshadowed by other obvious external wounds. After identification of a blast-related colorectal injury, the surgical options are primary repair (PR) or fecal diversion with delayed secondary repair.
This literature review was conducted to determine which patients would benefit from PR or from fecal diversion after colorectal blast injury.
Methods
The Prisma Statement Method for medical systematic review was used for this literature review. 3 The literature search was carried out using the “PubMed” online database from January 1993 through November 2012. Search criteria and results were:
-
1. (Blast OR War) AND (intestinal OR abdominal) AND perforation (45 articles)
-
2. Blast AND intestinal AND perforation AND surgery (17 articles)
The selection criterion was papers dealing with the keywords “blast and abdominal surgery in conflict.” The screening was performed by two independent reviewers.
The literature search identified 62 articles; duplicate papers were removed and title and article abstracts were screened to select those that met the inclusion criteria. Full-text versions of the selected articles were read to extract data. Only qualitative data were collected because of differences in study methods and definitions and lack of consistency among the retrieved papers.
Results
Five papers meet the inclusion criterion. All data from the papers were tabulated into the single review database. The papers selected contained accounts from the wars in Bosnia, Iraq and Afghanistan. A total of 319 victims were represented, with every victim suffering multiple injuries. The average age was 27 years, 93.3% were male and 90.6% were soldiers. Injuries were localized to the colon (descending 38.9%, ascending 29.4%, transverse 25.9%) and rectum (5.8%). Primary repair was performed on 161 (50.5%) victims and fecal diversion on 158 (49.5%). The average hospitalization was 22.2 days (this information was reported in just three articles).Reference Stankovic, Petrovic, Drinkovic, Bjelovic, Jevtic and Mirkovic 5 – Reference Vertrees, Wakefield and Pickett 7
Only three papers analyzed morbidity and mortality variation in the PR or ostomy group.Reference Hudolin and Hudolin 4 – Reference Strada, Raad, Belloni and Setti Carraro 6 Pooled results showed overall complications of 27.26% and mortality of 7.17%. However, authors of each of the three papers reported that PR did not present complications or mortality that were statistically different from fecal diversion (Tables 1 and 2).Reference Hudolin and Hudolin 4 – Reference Strada, Raad, Belloni and Setti Carraro 6
Table 1 Complications and Causes of Death
Table 2 Treatment, Mortality and Complications
Abbreviations: FD, fecal diversion; PR, primary repair.
adata are derived because the article considers primary repair or fecal diversion not only caused by blast, but also by gunshot wound, bullet, stabbing, and motor vehicle crushing.
Limitations
The primary limitation for the review was a lack of substantial data such that quantitative analysis could be conducted. In addition, articles retrieved for the review were not consistent in reporting of data.
Discussion
Colorectal injuries often are caused by blast. Until today, it was not clear whether the best surgical treatment for this type of injury was primary repair or fecal diversion. The papers reviewed emphasize how crucial the absence or the presence of shock and associated injuries is in the choice of surgical strategy.Reference Webster, Mercer, Schrager, Carrell and Bowley 2 , Reference Hudolin and Hudolin 4 , Reference Vertrees, Wakefield and Pickett 7 In particular, hemorrhagic shock is the primary cause of shock in the battlefield and is also one of the causes of death found in the review. Therefore, future research could focus on the importance of medical evacuation and the treatment on the field to ensure hemodynamic stability until surgery can be performed. As underscored by Markov et al,Reference Markov, DuBose and Scott 8 to reduce overall mortality, and also the mortality and complications also from colorectal injuries by blast, key aspects of an organized Joint Theater Trauma System (JTTS) are important, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines.Reference Markov, DuBose and Scott 8
Conclusion
The current literature available for this review showed that for patients who do not have associated intra-abdominal injuries (diaphragm, stomach, pancreas, spleen, or kidney) or hemodynamic instability, PR did not result in an increase for complications or mortality. It is reasonable to conclude that PR can be the treatment of choice for uncomplicated abdominal blast-related colorectal injuries.
